Single Well Circumscribed Breast Lesion

Benign

• nipple
• skin lesion
• cyst
• inflammatory lymph node
• fibroadenoma
• papilloma
• hamartoma

Malignant

• Phyllodes tumor
• mets
• medulary carcinoma
• mucoid carcinoma
• colloid carcinoma

Multiple Well Circumscribed Breast Lesions

Benign

• Skin lesions
• Inflammatory nodes
• cysts
• fibroadenomas

Malignant

• Mets

Ill-defined irregular breast opacities

Benign

• fat necrosis
• previous surgery
• radial scar/CSL
• Hamartoma
• breast abscess
• composite opacity

Malignant

• Carcinoma

Breast Microcalcifications Differential

Benign

• Sclerosing adenosis
• fibrocystic change
• vascular
• skin lesion

Malignant

• DCIS
• Invasive cancer

Edematous Breast Differential

Benign

• breast abscess
• medical – heart failure
• fluid overload, etc.
• radiotherapy
• recent surgery

Malignant

• Inflammatory carcinoma

BIRADS

0__ Incomplete: Your mammogram or ultrasound didn’t give the radiologist enough information to make a clear diagnosis; follow-up imaging is necessary

1__ Negative: There is nothing to comment on; routine screening recommended

2__ Benign: A definite benign finding; routine screening recommended

3__ Probably Benign: Findings that have a high probability of being benign (>98%); six-month short interval follow-up

4__ Suspicious Abnormality: Not characteristic of breast cancer, but reasonable probability of being malignant (3 to 94%); biopsy should be considered

5__ Highly Suspicious of Malignancy: Lesion that has a high probability of being malignant (>= 95%); take appropriate action

6__ Known Biopsy Proven Malignancy: Lesions known to be malignant that are being imaged prior to definitive treatment; assure that treatment is completed

Stereotatic Biopsy Dictation

CLINICAL HISTORY: [x] year old woman referred for stereotactic core biopsy of a cluster of indeterminate microcalcifications in the [left or right] breast noted on recent mammography at [place and date].

Technique: [x] breast stereotactic core biopsy. Unilateral [digital] mammography. Specimen radiography. Dated [x].

PROCEDURE: Preliminary grid localizing film confirms a [x] cm cluster of microcalcifications in the [location within the breast].

Following universal protocol, patient and site verification was performed with a “time out” prior to the procedure.
After obtaining informed consent, the patient was positioned prone on the stereotactic table and the target was localized with digital images. A [x] approach was used. The skin was cleansed with Chloraprep. Cutaneous and deeper subcutaneous anesthesia was achieved using [x] cc of 1% Lidocaine and [x] cc’s of 1% Lidocaine containing epinephrine respectively. A small scalpel incision was made. A 9 gauge ATEC probe was inserted and its accurate position confirmed with pre and post fire images on the first pass. A total of [x] core biopsy specimens were obtained.

[#of radiographs] specimen radiographs revealed calcification in [x] cores. Cores containing radiographically evident calcium were sent in one container of formalin and cores not containing radiographically evident calcium were sent in another container of formalin for pathologic analysis, results pending. A [x] clip was [x] deployed to mark the biopsy site.

Post procedure cranial caudal and medial lateral projections disclose the clip to be at the target site. There [ are or are no ] residual microcalcifications noted at the biopsy site.

Following the procedure, the wound was cleansed and compressed. Steri strips and sterile gauze were applied and the patient was given post biopsy instructions. She left the department in good condition. Dr. [x] was in attendance during the entire procedure.

CONCLUSION: Status post stereotactic core biopsy of [right/left]

Ultrasound Core Biopsy Dictation

CLINICAL HISTORY: [x] year old woman referred for ultrasound-guided biopsy of a mass in the [right/left] breast.
The lesion was noted on previous ultrasound performed at [x] on [date]. Recent mammogram performed at [x] on [date] [demostrated/failed to demonstrate] the lesion.

Technique: [x] breast ultrasound guided core biopsy dated [x].

PROCEDURE:
Preliminary ultrasound evaluation of the [right/left] breast with special attention to the area of [sonographic/mammographic/palpable] concern, confirms the presence of a [x] x [x] cm mass at the [x] o’clock position, approximately [x] cm from the nipple, at a depth of [x] cm from the skin.

Following universal protocol, patient and site verification was performed with a “time out” prior to the procedure.
Informed consent was obtained. The patient was positioned in the supine oblique position, and the lesion was localized with real-time sonography. The skin was cleansed with Chloraprep. [x] cc’s of 1% Lidocaine was used for local anesthesia. A [lateral/medial/oblique] approach to the target was used. An 18-gauge needle, secured to a spring-loaded device, was advanced to the preselected target. A total of [x] biopsy specimens were obtained, with pre- and post-fire images documenting needle placement for each pass. Specimens were sent for pathologic analysis, results pending.

Following the procedure, the wound was cleansed and compressed. Steri-strips and sterile gauze were applied and the patient was given post-biopsy instructions. The patient tolerated the procedure well and left the department in good condition.

Dr. [x] was in attendance during the entire procedure.

IMPRESSION

Ultrasound-guided core biopsy of [right/left] breast mass. Pathology pending.

Mammogram Needle Localization

CLINICAL HISTORY: [x] year old woman referred for needle-wire localization of a [mass/cluster of calcifications] in the [right/left] breast [x] noted on previous mammogram performed at [x] on [x].

PROCEDURE: Following a universal protocol, patient and site verification was performed with a “time out” prior to the procedure. Preliminary mammographic views of the [right/left] breast confirm the presence of a [x] cm [mass/cluster
of calcifications] in the [x], approximately [x] cm
from the nipple.

Informed consent was obtained. A localizing grid film was obtained. The skin was cleansed with ChloraPrep. [x] cc of 1% Lidocaine was used for local anesthesia. Using a [lateral/medial/superior/inferior] approach, a
[x] needle/wire assembly was used to localize the target. Post-localization mammographic views disclosed the target to be[ant/post/med/lat] to the [reinforced segment of the wire/distal portion of the needle].
Labeled films were sent with the patient to the OR.
The patient tolerated the procedure well and left the department in good condition.

A surgical specimen submitted for radiography
demonstrates the targeted [mass/calcifications] to be within the specimen. The [x] wire is intact. Dr. [x] was notified of these findings at the time of surgery.

IMPRESSION:
Needle/wire localization and documented surgical excision of [left/right] breast [x]
[mass/microcalcifications].

Ultrasound Needle Localization Dictation

CLINICAL HISTORY: [x] year old woman referred for needle localization of a mass in the [right/left] breast.
The lesion was noted on previous ultrasound performed at [x] on [x]. Recent mammogram performed at [x] on [x] revealed [x].

Technique: Needle localization under ultrasound guidance, specimen radiography

PROCEDURE: Following universal protocol, patient and site verification was performed with a “time out” prior to the procedure. Preliminary ultrasound of the [right/left] breast with special attention to the area of sonographic concern, confirms the presence of a [x] x [x] cm mass at the [x] o’clock axis, [x] cm from the nipple.

Informed consent was obtained. The patient was positioned in the supine oblique position. The skin was cleansed. 0.2 cc 1% Lidocaine was used for local anesthesia. Using a [lateral/medial/superior/inferior] approach, a [x] needle/wire assembly was used to localize the target under real-time sonographic guidance.
A post-localization mammographic view was obtained, and sent with the patient to the OR.

The patient tolerated the procedure well and left the department in good condition.

A surgical specimen submitted for radiography demonstrates the targeted lesion to be within the specimen. The [x] wire is intact. Dr. [x] was notified of these findings at the time of surgery.

IMPRESSION: Ultrasound-guided needle localization and documented excision [left/right] breast mass .

Screening Bilateral Breast Ultrasound Dictation

Clinical History: [x] year old woman referred for bilateral breast ultrasound. [x]

Comparison: [x]

Technique: Bilateral breast ultrasound dated [x]

Findings: Real time ultrasound of both breasts was performed as per clinical request. There is no sonographic evidence of a discrete cystic or solid lesion in either visualized breast.

Impression:

No sonographic evidence of a lesion in either breast.

Recommendation:

Screening mammogram in [x]

Findings and recommendations were discussed with the patient following this evaluation.

Right Unilateral Mammogram (s/p left mastectomy) Dictation

CLINICAL HISTORY: [x] year old woman status post left mastectomy for carcinoma in [x]. The patient is now referred for follow up right mammogram. [x]

TECHNIQUE: Unilateral right mammogram dated [x]

COMPARISON: [x]

FINDINGS:
The right breast is [almost entirely fatty.;
composed of scattered fibroglandular densities.;
heterogeneously dense, which may lower the sensitivity of mammography.;
extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient.]

No mammographically suspicious mass or suspicious cluster of calcifications are seen in the right breast.

IMPRESSION:
No mammographic evidence of malignancy in the right breast.

RECOMMENDATION:
Unilateral right mammogram in one year.

Findings and recommendations were discussed with the patient and she received a written record summarizing this report.

[BIRADS 2: Benign findings]

Left Unilateral Mammogram (s/p right mastectomy) Dictation

CLINICAL HISTORY: [x] year old woman status post right mastectomy for carcinoma in [x]. The patient is now referred for follow up left mammogram. [x].

TECHNIQUE: Unilateral left mammogram dated [x]

COMPARISON: [x]

FINDINGS:

The left breast is [almost entirely fatty.;
composed of scattered fibroglandular densities.;
heterogeneously dense, which may lower the sensitivity of mammography.;
extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient. ].

No mammographically suspicious mass or suspisious cluster of calcifications are seen in the left breast.

IMPRESSION:
No mammographic evidence of malignancy in the left breast. [x]

RECOMMENDATION:
Follow up left mammogram in one year. [x]

Findings and recommendations were discussed with the patient and she received a written record summarizing this report.

[BIRADS 2: benign findings]

Diagnostic Mammogram After Recall Dictation

Indication: [x] year old woman underwent screening mammography, [x], recalled for additional imaging of the [x] breast.

Technique: [x] unilateral mammogram, [x] breast sonogram

Comparison: [x]

Findings: [x]

Impression: [x]

Recommendation: [x]

These findings and recommendations were discussed with the patient and she received written record summarzing this report.

BIRADS [x]

S/P lumpectomy dictation

CLINICAL HISTORY: [x] year old woman status post [x] lumpectomy for carcinoma in [x]. The patient is now referred for follow up [x] mammogram.

TECHNIQUE: [x]

COMPARISON: [x]

FINDINGS:

[x] A scar marker was placed over the [x] of the [x] breast indicating cutaneous scarring from prior lumpectomy. Parenchymal distortion at the lumpectomy site is [x] and compatible with post surgical scarring. [x] [No suspicious mass or suspicious cluster of calcifications has developed in either breast.]

IMPRESSION:
[x]

RECOMMENDATION:
[x]

Findings and recommendations were discussed with the patient and she received a written record summarizing this report.

[BIRADS 2: Benign findings]

BIRADS 2 Dictation

2 D C

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

Comparison is made with [x]

The breast tissue is extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient.

No developing masses or suspicious clusters of microcalcifications are seen. Benign findings are present.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 2: Benign findings

2 D N

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

No prior films are currently available for comparison. If any prior films can be submitted, comparison will be performed and an addendum to this report will be issued.

The breast tissue is extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient.

No suspicious masses or suspicious clusters of microcalcifications are seen. Benign findings are present.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 2: Benign findings

2 F C

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

Comparison is made with [x]

The breast tissue is predominantly fatty. No developing masses or suspicious clusters of microcalcifications are seen. Benign findings are present.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 2: Benign findings

2 F N

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

Comparison is made with [x]

The breast tissue is predominantly fatty. No developing masses or suspicious clusters of microcalcifications are seen. Benign findings are present.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 2: Benign findings

2 H C

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

Comparison is made with [x]

The breast tissue is heterogeneously dense, which may lower the sensitivity of mammography. No developing masses or suspicious clusters of microcalcifications are seen. Benign findings are present.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 2: Benign findings

2 H N

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED: [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x].

Findings:

No prior films are currently available for comparison. If any prior films can be submitted, comparison will be performed and an addendum to this report will be issued.

The breast tissue is heterogeneously dense, which may lower the sensitivity of mammography. No suspicious masses or suspicious clusters of microcalcifications are seen. Benign findings are present.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 2: Benign findings

2 S C

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

Comparison is made with [x]

The breast tissue is composed of scattered fibroglandular densities. No developing masses or suspicious clusters of microcalcifications are seen. Benign findings are present.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 2: Benign findings

2 S N

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

No prior films are available for comparison. If films are submitted, comparison will be made and an addendum issued.

The breast tissue is composed of scattered fibroglandular densities. There are no mammographically suspicious masses or suspicious clusters of microcalcifications. Benign findings are present.

Impression: No mammographic evidence of malignancy.

Recommendation: In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 2: Benign findings

BIRADS 1 Dictation

1 D C

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

Comparison is made with [x]

The breast tissue is extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient.

No developing masses or suspicious clusters of microcalcifications are seen.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 1: Negative

1 D N

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]
Findings:

No prior films are available for comparison. If films are submitted, comparison will be made and an addendum issued.

The breast tissue is extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient. There are no mammographically suspicious masses or suspicious clusters of microcalcifications.

Impression: No mammographic evidence of malignancy.

Recommendation: In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 1: Negative

1 F C

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

Comparison is made with [x]

The breast tissue is predominantly fatty. No developing masses or suspicious clusters of microcalcifications are seen.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 1: Negative

1 F N

TECHNIQUE: SCREENING [ DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

No prior films are currently available for comparison. If any prior films can be submitted, comparison will be performed and an addendum to this report will be issued.

The breast tissue is predominantly fatty. No suspicious masses or suspicious clusters of microcalcifications are seen.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 1: Negative

1 H C

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

Comparison is made with [x]

The breast tissue is heterogeneously dense, which may lower the sensitivity of mammography. No developing masses or suspicious clusters of microcalcifications are seen.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 1: Negative

1 H N

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

No prior films are currently available for comparison. If any prior films can be submitted, comparison will be performed and an addendum to this report will be issued.

The breast tissue is heterogeneously dense, which may lower the sensitivity of mammography. No suspicious masses or suspicious clusters of microcalcifications are seen.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 1: Negative.

1 S C

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x]

Findings:

Comparison is made with [x]

The breast tissue is composed of scattered fibroglandular densities. No developing masses or suspicious clusters of microcalcifications are seen.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 1: Negative

1 S N

TECHNIQUE: SCREENING MAMMOGRAPHY DATED: [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x].

Findings:

No prior films are currently available for comparison. If any prior films can be submitted, comparison will be performed and an addendum to this report will be issued.

The breast tissue is composed of scattered fibroglandular densities. No suspicious masses or suspicious clusters of microcalcifications are seen.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 1: Negative

BIRADS 0 Dictation

TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED: [x]

Clinical Indication: Screening mammography. Last clinical breast exam: [x].

Findings:

[Comparison is made with prior mammograms dated; No prior films are currently available for comparison. If any prior films can be submitted, comparison will be
performed and an addendum to this report will be issued.]

[The breasts are almost entirely fatty.;
The breast tissue is composed of scattered fibroglandular densities.;
The breast tissue is heterogeneously dense, which may lower the sensitivity of mammography.;
The breast tissue is extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient.]

[x]

[No suspicious masses or suspicious clusters of microcalcifications are seen in the left/right breast.]

Impression:

[x]

Recommendation: [Comparison with prior mammograms is strongly recommended. If the patient is unable to obtain prior mammograms for comparison, the patient will be recalled for additional imaging of the [x]

BIRADS 0: Incomplete; need additional imaging evaluation